SKILL STATION-LUMBAR PUNCTURE

UNDER THE GUIDANCE OF

DR.SREELATHA
DR.V. KAVITHA
INTRODUCTION
• Lumbar puncture (LP) also known as spinal tap,is a medical procedure
in which a needle is inserted into the spinal canal to enable the
aspiration of cerebrospinal fluid for diagnostic or therapeutic
purposes,or for the introduction of medical compounds into CSF
spaces
ANATOMY
• LP should be performed distal to the spinal cord, at the level of the cauda
equina .
• At birth, the inferior tip of the spinal cord is located opposite the body of L3.
The vertebral column grows more rapidly than the spinal cord. As a result,
by adulthood, the tip of the spinal cord is at the inferior border of the body
of L1.
• In older children, LP can be performed from the L2-L3 interspace to the L5-
S1 interspace because these interspaces are below the termination of the
spinal cord. LP in children younger than 12 months must be performed
below the L2-L3 interspace .
• An imaginary line that connects the two posterior-superior iliac crests
intersects the spine at approximately the fourth lumbar vertebra . This
landmark helps to locate the L3-L4 and L4-L5 interspaces.
INDICATIONS OF LUMBAR
PUNCTURE
DIAGNOSTIC INDICATIONS
INFECTIONS:
• In case of suspected e.g. pyogenic meningitis, tuberculous meningitis,
viral encephalitis and cryptococcal meningitis.
• Febrile seizure in infants<12 months
 INFLAMMATORY:
• Multiple sclerosis:
• GBS-Albuminocytological dissociation
METABOLIC DISEASES:
Eg:In case of GLUT-1 defect,non ketotic hyperglycinemia or glycine
encephalopathy
MALIGNANCY: To check for metastasis.
Measurement of opening pressure for the diagnosis of idiopathic
intracranial hypertension
Suspected subarachnoid haemorrhage
THERAPEUTIC INDICATIONS
1)Intrathecal drug administration :
• Anticancer medications like methotrexate.
• Steroid administration in spinal arachnoiditis and TB meningitis to
prevent late fibrotic strictures.
2)Spinal anaesthesia
3)Radiological –To do myelogram and myelography.
4)Idiopathic intracranial hypertension.
 CONTRAINDICATIONS
ABSOLUTE CONTRAINDICATIONS

1.GCS<8 or deteriorating or fluctuating level of consciousness

2.Signs of increased ICP like Diplopia,abnormal pupillary
response,decerebrate or decorticating posture and low heart
rate,increased blood pressure,irregular respiration,papilloedema.
3.Soft tissue infection at the site of puncture which leads to epidural
abscess,intra medullary spinal abscess,discitis,vertebral osteomyelitis.
RELATIVE CONTRAINDICATIONS
1.Septic shock leading to hemodynamic compromise
2.Significant respiratory compromise
3.New focal neurological signs or seizures
4.Seizures within previous 30mins with or without attaining normal
consciousness
5.INR>1.5 or platelet count <50,000 or child on anticoagulant.
INDICATIONS OF NEUROIMAGING
BEFORE LP
• Focal neurological deficit:eg dilated non reactive pupil,gaze palsy
• Papilledema
• Coma
• CNS trauma
• Apnoea,bradycardia,HTN( ICP)
• Tonic seizure or tonic posturing
• Immunosupression
LUMBAR PUNCTURE
PROCEDURE
PREREQUISITES BEFORE
PERFORMING LP
• PATIENT COUNSELLING
• EQUIPMENT CHECK
• ADEQUATE ANALGESIA AND SEDATION
• CAREFUL POSITIONING OF THE CHILD
 INSTRUMENTS
The equipment required for lumbar puncture are:
1) Lumbar puncture tray which includes
- cotton balls / gauze pieces
- 1 Hole sheet (eye towel)
- 1 Artery forceps
- 3 Sterile vials
- 22 to 24G spinal needle
2) Povidone –Iodine (10%) solution
3) Isopropyl alcohol
4) Sterile gown, mask and cap -1 each ( disposable)
5) A pair of sterile gloves
6) Vital signs monitor or pulse oximetry
7) Resuscitation kit
LP NEEDLE
Most common needles that are used for L.P are 20 or 22 Gauge needles
 DRUGS
LOCAL ANALGESIA
1% Lidocaine is used for local analgesia .
The maximum safe dose of lidocaine is 3 mg/kg.
A 1% solution means 1000mg in 100 ml ( or 10 mg/ml ).

SEDATION
The drugs commonly used for sedation are midazolam and fentanyl .
The dose of midazolam is 0.1 mg /kg/dose and fentanyl is 1-2 mcg/kg/dose .
Drugs like ketamine should be avoided for sedation as this may result in raised intracranial
pressure.
POSITIONING OF THE CHILD
• LP is performed in the lateral recumbent or sitting position.
LATERAL RECUMBENT POSITION
• Place the child on the side near the edge of the examining table.
• The assistant should draw the knees upwards and flex the neck.
• One arm of the assistant should be around the posterior aspect of the
child’s neck and the other arm under the child’s knee.
• Satisfactory positioning requires:
The child’s hip and shoulder should be
kept perpendicular to the table in order to
maintain spinal alignment without rotation.
SITTING POSTION
• The sitting position may be preferred in children who have the
potential for developing respiratory compromise because of
hyperflexion of the neck in the lateral recumbent position .
• In addition, this position may improve flow of CSF in very small infants
(less than two weeks of age).
• The sitting position does not permit accurate
measurement of opening pressure and
should be avoided when manometry is required
.
 LUMBAR PUNCTURE
STEPS
1)The first step is to identify and mark the interspace where LP is
to be performed.
• An imaginary line that connects the two posterior superior iliac
crests intersects the spine at approximately the 4th lumbar
vertebrae.
• This landmark helps to locate the L3-L4 and L4-L5 interspace.
• As the spinal cord ends at upper border of L3 so LP should be
performed below this level.
2) Using sterile technique, clean the puncture site with isopropyl
alcohol ,10 percent povidone iodine and isopropyl alcohol in this order
• The area cleansed should be large from below the ribcage till the
sacrum and till the lateral aspects of the flanks.
• Clean the area in circles from center to outwards.
3)Place one set of sterile drapes underneath the patient and use a
surgical drape with an eyehole to cover above and around the puncture
site.
• The drapes should be conservatively used among infants and younger
children so as to able to monitor the infant during the procedure.
4)Placing the spinal needle in the subarachnoid space:
• Check the spinal needle to ensure that the stylet is firmly in place.
• Hold the spinal needle with one hand.
• Use the free thumb tip as a guide by holding it on the spinous process
above or below the desired interspace entry site.
• The needle is introduced in the midline into the selected space
with the bevel of the needle pointing upwards and 10-15 degrees
cephalad.
• Remove the stylet cautiously from time to time as the needle is
advanced to look for CSF.
• As the needle passes through the dura a sudden loss of resistance
is felt.
• The needle is advanced slightly more and the stylet if present is
removed
• When CSF return occurs, attach the manometer and measure the
opening pressure and then collect CSF for analysis.
• Once CSF is collected, replace the stylet and the needle is taken out
quickly.
• Wash the antiseptic solution off the skin and place a sterile adhesive
bandage or gauze dressing over the puncture site.
 MANOMETRY
• The opening pressure should be measured with manometry
whenever possible.
• Because the measurement may be unreliable, opening pressure
measurement may be deferred in infants younger than two years of
age, struggling or uncooperative patients, or LPs performed with the
patient in the sitting position.
• The manometer is attached to the spinal needle hub with a three-
way stop-cock .
• CSF is permitted to enter the manometer; opening pressure is
recorded at the highest level attained by the CSF in the manometer
column, ideally with the legs in extension.
• The CSF level fluctuates slightly with respiratory and cardiac cycles.
The presence of these fluctuations confirms placement of the spinal
needle in the subarachnoid space. The absence of fluctuations may
indicate that the needle is partially occluded by dura or a nerve root,
and the reading may be inaccurate.
• After the opening pressure has been measured, the stop-cock can be
used to transfer fluid from the manometer column to sterile tubes.
• Normal opening pressures range from 5 to 20 cm H2O in a relaxed
patient in the lateral recumbent position with the neck and legs
extended. The range can increase to 10 to 28 cm H2O in patients in
the lateral recumbent position with the neck and legs flexed.
 CEREBROSPINAL
FLUID COLLECTION
•.
Tube 1 Culture and gram stain

Tube 2 Glucose and protein

Tube 3 Cell count and differential count

Tube 4 Additional studies eg:AES profile,CBNAAT

TROUBLE SHOOTING
1)Bony resistance — Bony resistance occasionally is felt during
attempted LP.
Withdraw without exiting and redirect the needle
2)Dry tap/Poor flow —
• Rotating the spinal needle by 90 degrees
• Replacing the stylet and advancing the needle slightly
• Pulling the needle back to the subcutaneous tissue and redirecting
3)Traumatic puncture —
• The CSF typically clears as it is collected if the spinal needle is in the
subarachnoid space.
• The spinal needle should be removed if the bloody fluid clots in the
hub or does not clear.
• The LP should be reattempted, with a new needle, one space above.
COMPLICATIONS
 Do’s:
• Perform random blood sugar before doing lumbar puncture.
• Ensure that the resuscitation kit available to you is functioning well
Don’ts:
• Do not flex the neck
• Do not flex the hips beyond 90 degrees.
• Do not aspirate the CSF with a syringe.
POST PROCEDURE CARE:
• Cover puncture site with a band aid or occlusive dressing.
• Reassess the vitals and neurological state of the child post LP
• Advise rest and avoid vigorous activity following the procedure.
• Document in case sheet regarding the procedure,no of attempts
required,CSF appearance and post procedure vitals.
SUMMARY
• Identify the site
• Allow good arch
• Long axis of spine should be parallel to the table.
• Insert the needle with bevel up and stylet in place.
• Stylet can be removed once skin is pierced.
• Direct the needle towards the umbilicus.
• Never aspirate from the needle.
THANK YOU